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<h1 class="p_Heading1"><span class="f_Heading1">Cervical Cancer Case Finding</span></h1>

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<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A1_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A1','TOGGLE0186A1_ICON')">Purpose</a></span></td></tr></table></div><div id="TOGGLE0186A1" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>Cervical Cancer Case finding form is used to track information about cervical cancer screening and re-screening of HIV positive women.</p>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A2_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A2','TOGGLE0186A2_ICON')">Fill in a New Cervical Cancer Case Finding Form</a></span></td></tr></table></div><div id="TOGGLE0186A2" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>The active technical area should be Cervical Cancer Case Finding</p>
<p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">1.</span>From the Patient Home Page, click on the Create New Form link and select the Cervical Cancer Case Finding form</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">2.</span>Fill in the form, making sure you fill in the required fields. Note that some of the fields will be auto populated.</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">3.</span>Click Save</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">4.</span>IQCare displays a message alerting you of any required fields not filled in</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">5.</span>IQCare displays a message alerting you of a successful save and asks you if you wish to exit or stay on the form (for continued field data entry.) </p></td>
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</table>
</div>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A3_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A3','TOGGLE0186A3_ICON')">Update a Cervical Cancer Case Finding Form</a></span></td></tr></table></div><div id="TOGGLE0186A3" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">1.</span>To access a previously filled &nbsp;Cervical Cancer Case Finding register click on View Existing Forms and find the Cervical Cancer Case Finding you want to update and click the link</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">2.</span>Update the form</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">3.</span>Click Save</p></td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A4_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A4','TOGGLE0186A4_ICON')">Example Form</a></span></td></tr></table></div><div id="TOGGLE0186A4" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p><img src="kemohcervicalcancer.png" width="930" height="1386" alt="KEMOHCervicalCancer" style="border:none" /></p>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A5_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A5','TOGGLE0186A5_ICON')">Data Dictionary</a></span></td></tr></table></div><div id="TOGGLE0186A5" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<th colspan="8" style="vertical-align:top; width:1008px; height:28px; background-color:#0000ff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 11pt; font-weight: bold; color: #ffffff;">Cervical Cancer Screening Form</span></p>
</th>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Form/Registration</span></p>
</td>
<td style="vertical-align:top; width:155px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Field Name (no spaces)</span></p>
</td>
<td style="vertical-align:top; width:70px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Labeled (In the form)</span></p>
</td>
<td style="vertical-align:top; width:69px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Predefined field /existing</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Options/list/units</span></p>
</td>
<td style="vertical-align:top; width:148px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Nature of the field</span></p>
</td>
<td style="vertical-align:top; width:136px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Associated fields</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; background-color:#99ccff; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt; font-weight: bold;">Required Field (Yes/No)</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VisitDate</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">ServiceAreaCx</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Service Area</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">MCH/FP, CCC, GOPC, Outreach, OPD, Other</span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Visit Type</span></p>
</td>
<td style="vertical-align:top; width:155px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxVisitType</span></p>
</td>
<td style="vertical-align:top; width:70px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Visit Type</span></p>
</td>
<td style="vertical-align:top; width:69px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening, Postponed Cryotherapy Visit, Post Treatment Complication, Other Cervical Cancer related Treatment</span></p>
</td>
<td style="vertical-align:top; width:148px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:136px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Visit Type</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxScreening</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxVisitType_Screening</span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Visit Type</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxPostTreatmentComp</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Cryotherapy, LEEP, Other</span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxVisitType_Treatment Complication</span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Visit Type</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxPostTreatmentCompOther</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxVisitType_Other</span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Cervical Map</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CervicalMap</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Cervical Map</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes/No</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VIAResult</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VIA Result</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VIA Positive, VIA Negative, Suspicious of cancer, Other</span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VIAResultOther</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VIA Result Other</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VIAResult_Other</span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VILIResult</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VILI Result</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VILIResultOther</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VILI Result Other</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">VILIResult_Other</span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">PAPResult</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">PAP Smear Result</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">PAPResultOther</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">PAP Smear Result Other</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">PAPResult_Other</span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening Method &amp; Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">HPVResult</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">HPV Test Result</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Treatment</span></p>
</td>
<td style="vertical-align:top; width:155px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxTreatmentSVA</span></p>
</td>
<td style="vertical-align:top; width:70px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening today, Cryotherapy Performed Today</span></p>
</td>
<td style="vertical-align:top; width:69px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Checkbox</span></p>
</td>
<td style="vertical-align:top; width:136px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Treatment</span></p>
</td>
<td style="vertical-align:top; width:155px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxTreatmentCryoPost</span></p>
</td>
<td style="vertical-align:top; width:70px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Screening today, Cryotherapy postponed; Reason</span></p>
</td>
<td style="vertical-align:top; width:69px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Treatment</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxTreatmentPostCryoToday</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Postponed Cryotherapy done today</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Checkbox</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Treatment</span></p>
</td>
<td style="vertical-align:top; width:155px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxTreatmentOtherToday</span></p>
</td>
<td style="vertical-align:top; width:70px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Other cervical cancer specific treatment performed</span></p>
</td>
<td style="vertical-align:top; width:69px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Treatment</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxTreatmentOtherAilments</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Treatment for other ailments</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referral Out</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">ReferredTo</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referred To</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referral Out</span></p>
</td>
<td style="vertical-align:top; width:155px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxReferredOutReason</span></p>
</td>
<td style="vertical-align:top; width:70px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Reason</span></p>
</td>
<td style="vertical-align:top; width:69px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Site does not have cryotherapy machine, Large lesion, Suspect cancer, Other Gynecological problem (specify):</span></p>
</td>
<td style="vertical-align:top; width:148px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referral Out</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxReferredOtherGynae</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Other Gynecological problem (specify)</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxReferredOutReason</span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referral Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxLargeLesionResult</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Results of Large Lesion Referral</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">LEEP Performed, Other</span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referral Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxLargeLesionResultOther</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Result of Large Lesion Other</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Text single Line</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxLargeLesionResult_Other</span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Referral Result</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">CxSuspectCancerResult</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Results of Suspect Cancer Referral</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Cancer Confirmed, Cancer Not Confirmed</span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">HIV Status</span></p>
</td>
<td style="vertical-align:top; width:155px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">HIVStatus</span></p>
</td>
<td style="vertical-align:top; width:70px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">HIV Status</span></p>
</td>
<td style="vertical-align:top; width:69px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:106px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Positive, Negative, Unknown</span></p>
</td>
<td style="vertical-align:top; width:148px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Select List</span></p>
</td>
<td style="vertical-align:top; width:136px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:20px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:156px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Next Appointment</span></p>
</td>
<td style="vertical-align:top; width:155px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">AppointmentDate</span></p>
</td>
<td style="vertical-align:top; width:70px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Follow Up Date/Next Appointment</span></p>
</td>
<td style="vertical-align:top; width:69px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:106px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:148px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:136px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:40px; padding:4px; border:solid 1px #000000;"><p style="margin: 4px 0px 4px 0px;"><span style="font-size: 9pt;"> </span></p>
</td>
</tr>
</table>
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</td>
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